Stress is the combination of psychological, physiological, and
behavioral reactions that people have in response to events that
threaten or challenge them. Stress can be good or bad. Sometimes,
stress is helpful, providing people with the extra energy or
alertness they need. Stress could give a runner the edge he or
she needs to persevere in a marathon, for example. This good kind
of stress is called eustress. Unfortunately, stress is
often not helpful and can even be harmful when not managed
effectively. Stress could make a salesperson buckle under the
pressure while trying to make a sales pitch at an important
business meeting, for example. Moreover, stress can increase the
risk of developing health problems, such as cardiovascular
disease and anxiety disorders. This bad kind of stress is called distress,
the kind of stress that people usually are referring to when they
use the word stress.

A convenient way to think about stress is in terms of stressors
and stress responses. Stressors are events that threaten
or challenge people. They are the sources of stress, such as
having to make decisions, getting married, and natural disasters.
Stress responses are psychological, physiological, and behavioral
reactions to stressors. Anxiety, depression, concentration
difficulties, and muscle tension are all examples of stress
responses.

The connection between stressors and stress responses,
however, is not as straight forward as it may seem. Mediating
processes, for instance, stand in between stressors and stress
responses. Whether stressors lead to stress responses depends on
mediating processes like how people appraise potential stressors
and how well people are able to cope with the negative impact of
stressors. Furthermore, a number of moderating factors, such as
personality traits and health habits, influence the the links
between stressors and stress responses. These mediating processes
and moderating factors help determine whether people experience
stress-related problems like burnout, mental disorders, and
physical illness and are the focus of many stress management
techniques that emphasize cognitive-behavioral approaches,
relaxation, exercise, diet and nutrition, and medication.

II. Sources of
Stress

Stressors, the sources of stress, include three types of
events, referred to as daily hassles, major life events,
and catastrophes. Additionally, specific types of
stressors occur within certain domains in life, such as family,
work, and school.

A. Stressors

Daily hassles are the little hassles or annoyances that occur
practically everyday, such as having to make decisions, arguing
with friends and family, trying to meet deadlines at school or
work, and stepping on a piece of bubble gum that someone
carelessly spitted out. Although a wide variety of daily hassles
can be sources of stress, they often involve conflicts between
behaviors people may or may not want to do. If someone is
experiencing an approach-approach conflict, that person
has to choose between two attractive alternatives, such as going
on vacation or buying a new computer. If someone is experiencing
an avoidance-avoidance conflict, that person has to choose
between two unattractive alternatives, such as having a pet
"put to sleep" or spending the money on an expensive
surgical procedure for it. If someone is experiencing an approach-avoidance
conflict, that person has to choose whether to engage in an
activity that has both attractive and unattractive qualities,
such as mowing the lawn, an activity that would result in a nice
lawn but would not be enjoyable to do (Miller, as cited in
99).

In particular, daily hassles that involve interpersonal
conflicts seem to have an impact that lasts longer than does that
of most other daily hassles (25). Additionally,
according to a survey of middle-aged adults (87), the
top ten daily hassles are as follows:

Concerns about weight

Health of a family member

Rising prices of common goods

Home maintenance

Too many things to do

Misplacing or losing things

Yard work or outside home maintenance

Property, investments, or taxes

Crime

Physical appearance

In general, major life events do not appear to be significant
sources of stress (118). Accordingly, major life
events generally do not tend to be related to the health problems
that accompany stress (96; 148). Under some
circumstances, however, major life events can be sources of
stress. Whether major life events involve positive or negative
feelings, for instance, is relevant. Major life events that are
positive tend to have either trivially stressful or actually
beneficial effects (156; 164), but major life events
that are negative can be stressful and are associated with
medical problems (141). Examples of major life events
are getting married, getting divorced, and being fired from a
job.

Although they do not happen very often, when catastrophes do
occur, they can be tremendous sources of stress. One major type
of catastrophe is natural disasters. After people are exposed to
natural disasters, they are more anxious, have more bodily
complaints, drink more alcohol, and have more phobias (138).
A group of Stanford University students who completed a survey
before and after the 1989 San Francisco earthquake, for example,
were more stressed afterwards than they were beforehand (115).
War is another type of catastrophe. It is one of the most
stressful catastrophes that you could ever endure. Between 16%
and 19% of the veterans who served during Operation Desert Storm,
for example, had symptoms of posttraumatic stress disorder
(PTSD), such as recurrent memories, nightmares, restricted
emotions, sleep disturbances, and irritability (160).
PTSD is a mental disorder (described later) characterized by the
reexperiencing of stress responses associated with an earlier
traumatic event like withstanding a natural disaster or being
assaulted.

Compared to the impact of other types of events, the
cumulative effect of daily hassles over time are probably the
most significant sources of stress (33; 87; 98; 174).
An obvious reason why major life events and catastrophes are
probably less significant sources of stress is that people just
do not experience them as often. It is not every day that a
person spends time in prison or retires from a job, for instance.
Likewise, people do not have to and possibly never will face the
repercussions of a nuclear war, for instance, on a daily basis.

B. Life Domains

1. Family

Specific types of stressors that family members are exposed to
through their family include a lack of parent-child emotional
bonding, parental workload, misbehavior of children, teenage
pregnancy, lack of emotional closeness between spouses, poor
communication between spouses, tension between spouses, divorce,
remarriage, and maternal depression (48; 64; 116).
Additionally, a family member's job can interfere with his or her
home life (64).

Marital conflict is a good example of a daily hassle that is
specifically related to the family. Marital conflict tends to
occur when spouses come from different social and economic
backgrounds and the spouse of higher status emphasizes his or her
superiority. Marital conflict often occurs in the context of
unequal occupational statuses, for instance (121).

Teenage pregnancy, particularly the unplanned pregnancy of an
unmarried, teenage daughter, is a good example of a major life
crisis that is specifically related to the family. Regarding
teenagers who follow through with the pregnancy, this event leads
to several premature role transitions, such as the teenager
becoming a young mother and the mother becoming a young
grandmother (48). These kinds of role transitions tend
to be sources of distress in the family if new mothers are still
teenagers but sources of eustress if new mothers are age 20 or
older (30; 76). In cases in which teenagers terminate
the pregnancy, they tend to find it especially stressful if they
perceive a lack of support from their parents or the father of
the child, are less sure of their decision and coping abilities
beforehand, blame themselves for the pregnancy, or delay until
the second trimester (4).

2. Work

The specific types of stressors that employees are exposed to
in the workplace fall into four categories of demands: task
demands, interpersonal demands, role demands, and physical
demands (139). Among these categories, work
overload, boundary extension, role ambiguity, role
conflict, and career development are particularly
relevant stressors (117). Additionally, an employee's
home-life can interfere with his or her job (64).

Work overload is a good example of a daily hassle that is
particularly relevant in the workplace. When employees feel
overwhelmed from trying to work on more tasks than they can
handle or from trying to work on tasks that are too difficult for
them, they are suffering from work overload. Work overload is
common after layoffs among the remaining workers who are assigned
more tasks. It is also common among newly appointed managers who
feel unprepared for their new, unfamiliar roles (139).

Boundary extension is another good example of a daily hassle
that is particularly relevant in the workplace. Some jobs, such
as public relations and sales, require employees to work with
people in other occupational settings. Such boundary extension
can be difficult for employees, especially if it involves any of
the following difficulties:

Dealing with very diverse organizations

Maintaining frequent and long-term relations with people
in other organizations

Interacting in complex and dynamic environments

Not having screening mechanisms like secretaries or voice
mail

Participating in nonroutine activities

Trying to meet demanding performance standards (139)

Two more good examples of daily hassles that are particularly
relevant in the workplace are role ambiguity and role conflict.
When employees are unsure about what is expected of them, how to
perform their job, or what the consequences of their job
performance are, they are experiencing role ambiguity. When
employees finds it difficult to perform their job effectively
because of the multiple explanations about their job performance,
they are experiencing role conflict. Role conflict takes place in
five basic ways:

Receiving conflicting or incompatible expectations from
another employee

Receiving different expectations from two or more other
employees

Receiving expectations that lead to incompatible roles

Receiving too many expectations, expectations leading to
too many roles, or expectations leading to roles that are
too complicated

Having values and beliefs that conflict with expectations
(139)

Career development is a good example of a major life event
specifically related to work. Changing jobs or occupations can be
stressful. People may feel frustrated and afraid, for example,
after being laid off or fired from their job. Similarly,
employees may feel belittled or embarrassed after being demoted.
These feeling may be even more damaging for employees if such
changes in occupational status interfere with their family life (139).

3. School

As with work, work overload, role ambiguity, and role conflict
are daily hassles that are particularly relevant to students.
Students in college, for instance, often feel overwhelmed from
having too many assignments or assignments that are too
difficult. Additionally, they sometimes experience role ambiguity
in poorly designed courses or from poor instructors and sometimes
experience role conflict from instructors who seem to believe
that the students in their classes are not taking any other
classes. According to two surveys (8; 93), the
following stressors are particularly relevant for college
students:

Final grades

Excessive homework

Term papers

Examinations

Study for examinations

Time demands

Professors

Class environment

Among children and adolescents, transitions from one stage of
schooling to another are major life events that can be
significant stressors. The transition from elementary school to
junior high or middle school, for instance, can be a significant
stressor (32; 49).

III. Stress
Responses

Although the presence of stressors does not mean that stress
responses will necessarily follow, when they do, stress responses
are the way in which people react to stressors. They are the
experience of being stressed. Stress responses can be divided
into three categories: psychological responses, physiological
responses, and behavioral responses.

A. Psychological
Responses

When people react to stressors, a wide variety of cognitive
and emotional responses can occur. Examples of cognitive
responses are as follows:

Concentration problems

Indecision

Forgetfulness

Sensitivity to criticism

Self-critical thoughts

Rigid attitudes

Examples of emotional responses are as follows:

Nervousness

Tension

Irritability

Anger

Hostility

Sadness

Guilt

Shame

Moodiness

Loneliness

Jealousy (23; 99; 129)

B. Physiological
Responses

Physiological responses follow what is called the general
adaptation syndrome (GAS) (150; 151). The
GAS has three stages: alarm, resistance, and exhaustion.

The first stage, alarm, is basically the fight-or-flight
response, the various physiological changes that prepare the
body to attack or to flee a threatening situation. The sympathetic
branch of the autonomic nervous system (the part of
the nervous system that induces the physiological changes that
accompany arousal) is activated and prompts the release of two catecholamines
(one of several types of neurotransmitters, molecules
released from active nerve cells that influence the activity of
other nerve cells), epinephrine (also called adrenaline)
and norepinephrine (also called noradrenaline),
from the adrenal medulla (the inner part of the adrenal
glands sitting atop the kidneys). Additionally, glucocorticoids
(stress hormones) like cortisol are released from the adrenal
cortex (the outer part of the adrenal glands) (31; 126).

The following examples of physiological changes characterizes
the alarm stage:

Increased heart rate

Increased blood pressure

Rapid or irregular breathing

Muscle tension

Dilated pupils

Sweating

Dry mouth

Increased blood sugar levels (23)

In the second stage, resistance, the body tries to calm itself
and restrain the fight-or-flight response from the alarm stage.
These changes allow people to deal with stressors more
effectively over a longer period of time (23).

When the body eventually runs out of energy from trying to
resist stressors, the exhaustion stage takes over. In this stage,
the body admits defeat and suffers the negative consequences of
the stressors, such as a decreased capacity to function
correctly, less sleep, or even death (23).

C. Behavioral
Responses

People act differently when they are reacting to stressors.
Sometimes, the behaviors are somewhat subtle, such as the
following responses:

Strained facial expressions

A shaky voice

Tremors or spasms

Jumpiness

Accident proneness

Difficulty sleeping

Overeating or loss of appetite (23; 116; 129)

Behavioral responses are more obvious when people take
advantage of the preparatory physiological responses of the
fight-or-flight response. One side of the fight-or-flight
response is that it prepares people to "fight", and
people sometimes take advantage of that feature and behave
aggressively toward other people. Unfortunately, this aggression
is often direct toward family members. After Hurricane Andrew
devastated south Florida in 1992, for example, reports of
domestic violence doubled. The other side of the fight-or-flight
response is that it prepares people for "flight" (23;
116; 129).

The following behavioral responses are examples of how people
try to escape threatening situations:

Quiting jobs

Dropping out of school

Abusing alcohol or other drugs

Attempting suicide

Commiting crimes (23; 116; 129)

IV. The
Connection Between Stressors and Stress Responses

Stressors prompt stress responses, right? Well, it depends. A
number of conscious and unconscious things occur in our inner
world that determine whether a stressor in the external world
will trigger our stress response. These inner world happenings
are referred to as mediating processes and moderating
factors.

A. Mediating Processes

Mediating processes in our inner mind/body world begin to
influence the quality and intensity of our stress response from
the moment we are exposed to a stressor. Consider, for example, a
person who discovers that his or her cat neglected to use the
litter box. Whether or not this person appraises the problem as
something he or she can establish control over may help determine
whether he or she becomes angry. Mediating processes include appraisal
and coping.

1. Appraisal

Once people become aware of a stressor, the next step is
appraisal. How a stressor is appraised influences the extent to
which stress responses follow it (98). In fact, many
stressors are not inherently stressful (173).
Stressors can be interpreted as harm or loss, as threats, or as
challenges. When stressors have not already led to harm or loss
but have the potential to do so, it is usually less stressful for
people if the stressors are seen positively as challenges rather
than negatively as threats (66; 98; 134). The
influence of appraisal does have its limits, though. For example,
although people who suffer from chronic pain tend to be able to
enjoy more physical activity if they view their pain as a
challenge they can overcome, appraisal does not matter if the
pain is severe (85).

Moreover, thinking negatively about the influence of past
stressors is associated with a greater vulnerability to future
stressors (71). Consider, for example, people with
PTSD. Among victims of sexual or physical assault with PTSD,
those who have trouble recovering tend to have more negative
appraisals of their actions during the assault, of others'
reactions after the assault, and of their initial PTSD symptoms (46).

An important aspect of appraisal is how predictable and
controllable a stressor is judged to be. Regarding
predictability, not knowing if or when a stressor will come
usually makes it more stressful, especially if it is intense and
of a short duration (1). After a spouse passes away,
for example, the other spouse tends to feel more disbelief,
anxiety, and depression if the death was sudden than if it was
anticipated weeks or months in advance (120).
Similarly, during the Vietnam War, for example, wives of soldiers
who were missing in action felt worse than did wives of soldiers
who were prisoners of war or had been killed (Hunter, as
cited in 23). Regarding control, believing that a stressor
is uncontrollable usually makes it more stressful. Alternatively,
believing that a stressor is controllable, even if it really is
not, tends to make it less stressful (166). When
people are exposed to loud noises, for example, they tend to see
it as less stressful when they are able to stop it, even if they
do not bother to stop it (67).

How much more stressful a stressor becomes from feeling a lack
of control over it depends, however, on the extent to which the
cause of the stressor is seen as stable or unstable,
global or specific, and internal or external.
Stable and unstable causes represent causes that are enduring and
temporary, respectively. Global and specific causes represent
causes that are relevant to many events and relevant to a single
occasion, respectively. Internal or external causes represent
causes that are the result of personal characteristics and
behaviors or the result of environmental forces, respectively.
The more stable and global the cause of a stressor seems, the
more people feel and behave as though they are helpless.
Likewise, the more internal the cause of a stressor seems, the
worse people feel about themselves. Together, these feelings and
behaviors contribute to a depressive reaction to the stressor (2).

Consider, for example, a case in which a guy's girlfriend
breaks up with him and he thinks that his love life is always in
the dumps (i.e., a stable interpretation), that nobody really
cares about him (i.e., a global interpretation), and that he must
not be a dateable guy (i.e., an internal interpretation). Such an
interpretation could contribute to a depressive reaction, such as
him coming to the conclusion that he might as well not try
because there is nothing he can do about it and that he is pretty
much a lost cause (27).

2. Coping

After a stressor has been appraised, the next step, if
necessary, is coping. How well people are able to cope with
stressors influences the extent to which stress responses follow
them. Coping strategies can be divided into two broad categories:
problem-focused coping and emotion-focused coping(98,
122). Problem-focused coping involves trying to manage or
to alter stressors, and emotion-focused coping involves trying to
regulate the emotional responses to stressors. Although people
tend to use both forms of coping in most cases (60),
the relative use of each of these forms of coping largely depends
on the context. Problem-focused coping is more appropriate for
problems in which a constructive solution can be found, such as
family-related or work-related problems. Alternatively,
emotion-focused coping is more appropriate for problems that just
have to be accepted, such as physical health problems (168).

Problem-focused coping strategies include the following three
types:

Confronting, which means changing a stressful
situation assertively. For example, "I stood my
ground and fought for what I wanted."

Seeking social support, which means obtaining
emotional comfort and information from other people. For
example, "I talked to someone to find out more about
the situation."

Planful problem solving, which means solving a
stressful problem through deliberate problem-focused
strategies. For example, "I made a plan of action
and followed it" (61; 62; 162)

The seeking of social support, in particular, appears to be a
valuable problem-focused coping strategy. Social support has been
shown to help with stressors like cancer, crowding, military
combat, natural disasters, and AIDS (23).

Accepting responsibility, which means
acknowledging one's role in a stressful problem. For
example, "I realized I brought the problem on
myself."

Escaping/Avoiding, which means wishful thinking
or escaping or avoiding a stressful situation by way of
activities like eating, drinking, or using alcohol or
other drugs. For example, "I wished that the
situation would go away or somehow be over with" (61;
62; 162)

B. Moderating Factors

Moderating factors influence the strength of the stress
responses induced by stressors or the direction of the relation
between stressors and stress responses. Regarding the previous
example about the cat and the litter box, how angry the person
becomes after finding out that his or her cat neglected to use
the litter box may depend on, for instance, how anxious or tense
he or she is in general. Mediating processes include appraisal
and coping. Moderating factors include personality traits,
health habits, coping skills, social
support, material resources, genetics and early
family experiences, demographic variables, and preexisting
stressors.

1.
Personality Traits

Two general personality traits, positive affectivity
(also called extroversion)and negative
affectivity (also called neuroticism), are
particularly relevant to stress. People who are high in positive
affectivity tend to have positive feelings like enthusiasm and
energy (171), feelings that characterize eustress.
People who are high in negative affectivity tend to have negative
feelings like anxiety and depression (170), feelings
that characterize distress. In particular, negative affectivity
is associated with the ineffective use of coping strategies (24;
109) and susceptibility to daily stressors (26).

Another personality trait relevant to stress is optimism,
a general tendency to expect that things will work out for the
best (144; 145). Optimism is associated with stress
resistance. Students who are optimistic, for example, tend to
have fewer physical responses to stressors at the end of an
academic term than do students who are pessimistic (9).
Even when taking into account other personality traits like
negative affectivity, perceived control, and self-esteem,
optimism is still associated with a lack of stress responses like
depression (146).

As stated previously, appraising the causes of a stressor as
stable, global, and internal contributes to a depressive reaction
to the stressor. Such appraisals are usually made by people who
have a general tendency for this kind of appraisal, referred to
as a pessimistic explanatory style or a depressive
explanatory style (27). Such people tend to have
more depressive reactions to stressors in general (161).

Hardiness is composed of a set of three related
personality traits: control, commitment, and challenge.
Control refers to the belief in people that they can influence
their internal states and behavior, influence their environment,
and bring about desired outcomes. Commitment refers to the
tendency for people to involve themselves in what they encounter.
Challenge refers to the willingness in people to change and try
new activities, which provides opportunities for personal growth (129;
163). Hardiness is associated with stress resistance (91;
92). In particular, hardiness is associated with favorable
appraisals of potential stressors (5; 172) and
effective use of coping strategies (175). Of the three
personality traits that comprise hardiness, control appears to be
the most important (35; 58). For instance, when people
feel unable to control their environment, cortisol levels rise in
the body (135). This process can take place in
response to crowding, for example, in places like high-density
residential neighborhoods, prisons, and college dormitories (57;
119).

Self-esteem, how people tend to feel about themselves,
is another personality trait that is relevant to stress.
Self-esteem is one factor that can influence the relation between
daily hassles and emotional responses to stressors (41).
Additionally, low self-esteem is associated with increased blood
pressure in response to stressors (147) and other
physiological responses that often occur in response to
stressors, such as trembling hands, pounding heart, pressures or
pains in the head, sweating hands, and dizziness (137).
Low self-esteem also has an important role in depression (17).

Power motivation is also a personality trait that is
relevant to stress. People who have a strong need for power are
described as competitive and aggressive, interested in the
accumulation of things and memberships, and prefer action over
reflection (107). Power motivation is associated with
stress responses to stressors (59). Inhibited power
motivation, having a strong need for power that is not being
satisfied, for instance, is associated with physiological
responses that often occur in response to stressors like high
levels of norepinephrine (108) and high diastolic
blood pressure (106).

2. Health
Habits

People are particularly resistant to stress if they lead a
healthy lifestyle, which includes a healthy diet, physical
fitness, and enough rest and relaxation. In particular, people
who lead a healthy lifestyle have the energy they need to cope
with stressors (98).

A healthy diet is an important factor in stress resistance,
and meals can be a time to reduce stress by relaxing and
socializing. Moreover, an unhealthy diet often leads to weight
gain, which can become a stressor itself. A healthy diet involves
making time for meals, eating meals that have a variety of foods
but plenty of grains, fruits, and vegetables and that are low in
fat, salt, and sugar, avoiding caffeine, not drinking alcohol,
and not smoking cigarettes (54). Additionally, the
following nutrients are essential to keep stress under control:
carbohydrates, protein, linoleic acid (vegetable fat), B
vitamins, vitamin C, vitamin E, gamma-aminobutyric acid (GABA) (11;
54).

Physical fitness makes people less vulnerable to stress
responses (29). Stressors tend to prompt weaker
physiological responses, such as lower levels of cardiovascular
arousal, in people who are physically fit than they do in people
who are not physically fit (40; 79). Similarly,
stressors tend to prompt weaker psychological responses, such as
lower levels of anxiety, emotionality, and depression, in people
who are physically fit than they do in people who are not
physically fit (43; 53; 79; 82; 103).

When people relax and allow themselves to rest, they enter a
state of reduced psychological and physiological arousal (140).
Because this state is basically the opposite of a stressful
state, a person who is relaxed and continues to relax when
exposed to a stressor usually ends up preventing the stress
responses or reducing their intensity. Furthermore, rest allows
people to unwind and recover from stressful experiences, giving
them the energy they need to deal with stress (Stoyva &
Budzynski, as cited in 157).

3. Coping
Skills

If people do not have adequate coping skills, they cannot cope
effectively with stressors and the stress responses that follow.
In such cases, coping strategies cannot act as effective
mediating processes. Two examples of coping skills are
problem-solving skills and social skills.

Problem-solving skills include the following abilities:

Looking for information

Identifying problems and figuring out possible ways they
could be solved

Comparing the various problem-solving strategies

Considering the various strategies with respect to
desired or anticipated outcomes

Selecting problem-solving strategies to use

Problem-solving skills are important coping resources because
they enable people to handle the problems posed by stressors (98).

Social skills are also important coping resources because
social interaction is part of so many stressful situations. They
refer to the ability to communicate and behave with other people
in ways that are socially appropriate and effective. Moreover,
they can help people with problem solving in social situations by
giving them more control over the relevant social interactions,
such as increasing the likelihood of other people cooperating and
offering support (98).

4. Social
Support

People tend to respond better to stressors if they have a social
support network, other people that they can rely on for
support, than if they do not (149). Four types of
social support are as follows:

Appraisal support, which helps people better
understand stressors and identify coping strategies that
may be appropriate

Tangible support, which takes place when other
people provide material support, such as money and goods
and services

Information support, which takes place when
other people provide specific information about stressors
and appropriate coping strategies

Emotional support, which reassures people that
they are valuable and cared for by other people (163)

Social support is not always beneficial, though. For social
support to be beneficial, people must believe that other people
care about them and are willing to help them (125; 97).
Additionally, social support networks can sometimes become
annoying, disruptive, or interfering and actually end up
increasing stress (28), such as when they provide too
much support or the wrong kind of support (23).

5. Material
Resources

Material resources refer to money and the goods and
services that money can buy. Material resources generally
increase the coping options available to people and to improve
the access to and effectiveness of legal, medical, financial, and
other professional assistance. People who have money tend to cope
well with stressors, especially if they know how to use it. Even
if they do not spend it, the comfort of simply having money
available is associated with a lack of vulnerability to stressors
(98).

6. Genetics
and Early Family Experiences

The genes and childhood experiences that people have seem to
have an influence on several moderating factors (143; 163).
The general tendency to experience positive and negative
affectivity (123), to be optimistic (127),
to use active coping strategies like planful problem solving and
seeking social support (88), or to rely on social
support networks (89), for example, is partially
inherited. Likewise, the general tendency to feel a sense of
personal control (165), to use denial to cope with
stressors (88), or to respond to stressors with
hostility and anger (3), for example, is partially do
to family experiences during childhood. Furthermore, genetic and
familial influences themselves can be moderating factors in the
stress process. The general tendency to have mental disorders
that involve anxiety or depression, for example, is influenced by
genetic and familial factors (72).

7.
Demographic Variables

Demographic variables like age, ethnicity, gender,
socioeconomic status, occupational status, and urban/rural have
an influence on several moderating factors (143).
Regarding positive and negative affectivity, for instance, people
tend to experience them less with age, Blacks tend to experience
less positive affectivity with age than do people of other
ethnicities, and women tend to experience negative affectivity
more than men do (39; 52). Additionally, people of
lower socioeconomic status or who live in urban areas tend to
experience more negative affectivity than do people of higher
socioeconomic status or who live in rural areas, respectively (52).
Regarding self-esteem, for instance, people of higher
occupational status tend to have higher self-esteem than do those
of lower occupational status (94; 95).

Furthermore, the demographic variables themselves can be
moderating factors in the stress process (84).
Regarding gender differences in coping, for instance, men tend to
use the following types of coping:

Problem-focused coping strategies

Planned and rational actions

Positive thinking

Personal growth

Humor

Daydreaming

Fantasies

Women tend to use the following types of coping:

Emotion-focused coping strategies

Self-blame

Expression of emotions

Seeking of social support

Wishful thinking (167)

Additionally, people of lower socioeconomic status tend to
encounter more stressors, to have less social support, and to be
less in control of their environment than people of higher
socioeconomic status tend to (45; 155).

8.
Preexisting Stressors

The influence that one stressor has depends in part on other
ongoing stressors (163). Chronic stressors, in
particular, seem to intensify the impact of other stressors that
people are exposed to at the same time (56; 100).
Sometimes, however, chronic stressors may actually improve
resistance to other minor stressors because they seem less
important in comparison (163) but only when the other
stressors occur in unrelated contexts (70).

V. Problems
Associated With Stress

Stress responses are potentially harmful, especially if they
are severe or extend over a long period of time. When stressors
end up leading to stress responses, a number of problems can
arise, such as burnout, mental disorders, and physical
illnesses. Moreover, stress responses, such as emotional
responses like anxiety and worry and cognitive responses like
having a poor or hopeless attitude, can even worsen any pain that
people may be feeling (99).

A. Burnout

Burnout is an increasingly intense pattern of psychological,
physiological, and behavioral dysfunction in response to a
continuous flow of stressors or chronic stress (110; 142).
It is commonly found among employees and professionals who have a
high degree of personal investment in work and high performance
expectations. In the initial stages, people often have a variety
of physiological and behavioral symptoms and lose interest and
confidence in their work. The following physiological symptoms
may occur:

Shortness of breath

Loss of appetite or weight

Headache

Fatigue and exhaustion

The following behavioral symptoms may occur:

Lack of interest in fellow employees

Risky behavior

Mood swings

In the later stages, people often do the following things:

Abuse alcohol and other drugs

Smoke excessively

Drink more caffeinated beverages

Become more rigid in their thinking

Lose faith in the abilities of co-workers, management,
the organization, and themselves

Become less productive (117)

Another concept, ego depletion, is very similar to
burnout. In fact, it may represent an underlying feature of
burnout. The idea behind ego depletion is that acts of
volitionmaking choices and decisions, taking
responsibility, initiating and inhibiting behavior, and making
plans of action and carrying them outdraw on a limited
supply of volitional energy that is available inside people.
Consequently, if people deplete this resource too much, it is no
longer very easy to do what they need to do to handle stress,
such as trying to use coping strategies in response to stressors (14).

B. Mental Disorders

Mental disorders are the result of a varying combination of
sources, one of which being stress. Examples of other sources are
as follows:

Chemical imbalances

Inherited characteristics

Early learning experiences

Brain damage

Psychological traits

The diathesis-stress model explains how stress
contributes to the onset of mental disorders. According to this
model, chemical imbalances, inherited characteristics, and early
learning experiences can make it more likely for people to get
mental disorders but whether they do depends on the stressors
they encounter (114).

People sometimes have symptoms of mental disorders, but they
usually do not meet the criteria or are not clinically
significant, severe enough to necessitate treatment. Before a
person can be diagnosed with a mental disorder, his or her
problematic thoughts, feelings, and actions must meet the
criteria for the mental disorder and must prevent adequate
social, occupation, or other forms of functioning (7).
Accordingly, answering yes to any of the following
questions may suggest clinical significance:

Is the behavior considered strange within the person's
own culture?

Does the behavior cause personal distress?

Does the behavior interfere with what the person is
trying to accomplish?

Is the person a danger to self or others?

Is the person legally responsible for his or her acts? (177)

Stress may play a causal role in a wide variety of mental
disorders. Some of the mental disorders in which stress appears
to have a causal role are anxiety disorders, mood
disorders, and substance-related disorders.

1. Anxiety
Disorders

Anxiety disorders are characterized by anxiety, either as the
primary symptom or the primary cause of other symptoms (80).
The presence or absence of panic attacks or agoraphobia
is a critical aspect of several disorders. A panic
attack " is a discrete period in which there is the sudden
onset of intense apprehension, fearfulness, or terror, often
associated with feelings of impending doom. During these attacks,
symptoms such as shortness of breath, palpitations, chest pain or
discomfort, choking or smothering sensations, and fear of 'going
crazy' or losing control are present" (7, p. 393).
Agoraphobia "is anxiety about, or avoidance of, places or
situations from which escape might be difficult (or embarrassing)
or in which help may not be available in the event of having a
Panic Attack or panic-like symptoms" (7, p. 393).

Twelve different anxiety disorders can be diagnosed:

Panic disorder without agoraphobia "is
characterized by recurrent unexpected Panic Attacks about
which there is persistent concern" (7, p. 393).

Posttraumatic stress disorder "is
characterized by the reexperiencing of an extremely
traumatic event accompanied by symptoms of increased
arousal and by avoidance of stimuli associated with the
trauma" (7, p. 393).

Acute stress disorder "is characterized by
symptoms similar to those of Posttraumatic Stress
Disorder that occur immediately in the aftermath of an
extremely traumatic event" (7, p. 393).

Anxiety disorder due to a general medical condition "is
characterized by prominent symptoms of anxiety that are
judged to be a direct physiological consequence of a
general medical condition" (7, p. 394).

Substance-induced anxiety disorder "is
characterized by prominent symptoms of anxiety that are
judged to be a direct physiological consequence of a drug
of abuse, a medication, or toxin exposure" (7,
p. 394).

Anxiety disorder not otherwise specified is used
as a diagnosis when anxiety symptoms do not meet the
criteria for other disorders or when there is inadequate
or contradictory information about anxiety symptoms (7).

Regarding the causal role of stress in anxiety disorders,
stressors appear to have a causal influence (12; 101).
The specific way in which stressors lead to the onset of anxiety
disorders, however, varies depending on the type of anxiety
disorder (55). Additionally, posttraumatic stress
disorder can be thought of as a prolonged and severe stress
response to a catastrophe or to a chronic intense stressor (177).

Major depressive disorder "is characterized
by one or more Major Depressive Episodes" (7,
p. 317).

Dysthymic disorder "is characterized by at
least 2 years of depressed mood for more days than not,
accompanied by additional depressive symptoms that do not
meet criteria for a Major Depressive Episode" (7,
p. 317).

Depressive disorder not otherwise specified is
used as a diagnosis when the depressive symptoms do not
meet the criteria for other disorders or when there is
inadequate or contradictory information about the
depression symptoms (7).

Bipolar I disorder "is characterized by one
or more Manic or Mixed Episodes, usually accompanied by
Major Depressive Episodes" (7, p. 317).

Bipolar II disorder "is characterized by one
or more Major Depressive Episodes accompanied by at least
one Hypomanic Episode" (7, p. 318).

Cyclothymic disorder "is characterized by at
least 2 years of numerous periods of hypomanic symptoms
that do not meet criteria for a Manic Episode and
numerous periods of depressive symptoms that do not meet
criteria for a Major Depressive Episode" (7, p.
318).

Bipolar disorder not otherwise specified is used
as a diagnosis when the bipolar symptoms do not meet the
criteria for other disorders or when there is inadequate
or contradictory information about the bipolar symptoms (7).

Mood disorder due to a general medical condition
"is characterized by a prominent and persistent
disturbance in mood that is judged to be a direct
physiological consequence of a general medical
condition" (7, p. 318).

Substance-induced mood disorder "is
characterized by a prominent and persistent disturbance
in mood that is judged to be a direct physiological
consequence of a drug of abuse, a mediation, another
somatic treatment for depression, or toxin exposure"
(7, p. 318).

Mood disorder not otherwise specified is used as a
diagnosis when the mood symptoms do not meet the criteria
for other disorders or when there is inadequate or
contradictory information about the mood symptoms (7).

Regarding the causal role of stress in mood disorders,
negative major life events tend to precede depression (177).
In fact, compared to the number of negative major life events
experienced by people who are not depressed, people who become
depressed experience two to three times as many shortly
beforehand (73).

3.
Substance-Related Disorders

Substance-related disorders are characterized by the use of
drugs like alcohol, cocaine, heroin, and other substances people
use to alter the way they think, feel, and act (13).
Substance-related disorders fall into two categories: substance
use disorders and substance-induced disorders.
Substance use disorders are characterized by a problematic
pattern of substance use, involving dependence on or abuse of
substances. Substance-induced disorders are characterized by
reactions to the effect of substances on the central nervous
system, involving intoxication, withdrawal, and sets of
substance-induced features that resemble other disorders (63,
1995). Regarding the causal role of stress in
substance-related disorders, the need to reduce stress may be one
of the initial causes of substance abuse (23).

C. Physical Illnesses

Stress is a health hazard. Stress can lead to a variety of
physical illnesses and related health problems. In fact, stress
has a negative impact on virtually every organ system in the
body:

Cardiovascular system

Respiratory system

Endocrine system

Gastrointestinal tract

Male and female reproductive systems

Immune system (81)

Some physical illnesses, such as peptic ulcers, are caused by
physiological responses to stressors. Other physical illnesses,
such as asthma and skin rashes, however, can occur in the absence
of stress but are aggravated by it. Regarding the changes in body
chemistry that accompany physiological responses to stressors,
increased levels of glucocorticoids are usually more harmful to a
person's health than are increased levels of epinephrine and
norepinephrine. Prolonged exposure to high levels of
glucocorticoids can lead to the following problems:

Increased blood pressure

Damaged muscle tissue

Infertility

Inhibitted growth

Immune system suppression

Brain damage

Accelerated aging (31)

In particular, stress appears to be a cause of immune
system suppression and cardiovascular diseases and
an influence on the course of cancer.

1. Immune
System Suppression

Physiological response to stressors can impair the function of
the immune system, which leaves people vulnerable
illness-promoting substances like viruses, bacteria, and fungi.
When a married person dies, for example, it is often the case
that his or her spouse dies soon afterward from an infection (31).
Additionally, people who are more stressed are more likely to
catch a cold than are people who are less stressed, for example (36;
37).

2.
Cardiovascular Diseases

Cardiovascular diseases typically involve high blood pressure
and a high level of cholesterol in the blood. People with
cardiovascular diseases are prone to have heart attacks and
strokes (31). A certain pattern of psychological
responses to stressors, referred to as cynical hostility,
is a risk factor for coronary heart disease and heart attacks (153).
Cynical hostility is characterized by the following thoughts and
feelings:

Suspiciousness

Resentment

Frequent anger

Antagonism

Distrust of others (154; 176)

3. Cancer

Although stress may not cause cancer, it can contribute to it
by weakening the body's natural defenses against cancerous cells (86).
Furthermore, this influence may be particularly strong for people
who have major depression, feel hopeless, and are indifferent
toward the pain (38). For example, mastectomy patients
who are determined to overcome their breast cancer tend to be
more likely to survive than mastectomy patients who feel hopeless
and are indifferent toward the pain tend to be (75; 124).

VI. Stress
Management

To avoid the problems associated with stress, people need to
manage their stress. Before they can manage their stress,
however, they need to decide whether they need professional
help or whether self-help is enough. Once people
decide on a source of help, regardless of the source of the help
and the stress management techniques involved, a series
of steps are involved in the process of change.

A. Professional
Help or Self-Help?

When trying to manage stress, it is often difficult for people
to decide whether self-help will be enough or whether they should
seek professional help. In practice, people usually turn to
self-help instead of professional help. The public appears to be
very accepting of self-help resources (128; 169).
Self-help is not always the best way to manage stress, though.
Sometimes professional help is necessary. Professional help is
probably necessary if self-help fails or does not offer any
worthwhile solution or if the problems associated with stress
develop into mental disorders or physical illness.

When people realize that they do in fact need to seek
professional help, how do they know what type of professional to
turn to? A wide range of professionals is available to people
with stress-related problems, ranging from medical doctors to
mental health professionals. A medical doctor, such as a general
practitioner or a specialist, is a good choice when stress leads
to symptoms that may indicate physical illnesses. A mental health
professional, such as clinical psychologist or a psychiatrist,
is a good choice when stress leads to symptoms that may indicate
a mental disorder. Clinical psychologists and psychiatrists along
with other mental health professionals like counseling
psychologists can also provide assistance with stress
management in general, not just with mental disorders that may
accompany stress. Other mental health professionals like marriage
and family counselors, social workers, nurses, clergypersons, and
telephone crisis counselors may also be able to provide some
assistance with stress management.

Clinical or counseling psychologists usually earn a Ph.D.,
doctor of philosophy, (or sometimes a Psy.D., doctor of
psychology, or Ed.D, doctor of education.) in psychology.
Psychiatrists earn an M.D., medical doctor, degree. Compared to
psychiatrists, clinical psychologists tend to focus more on the
aspects of mental disorders that involve problematic thoughts,
feelings, and actions and problems with relationships with other
people. They also usually receive more extensive training in
therapy. Psychiatrists, however, tend to view mental disorders as
medical problems that should be treated with drugs and typically
receive less training in actual therapy (13; 99).
Whether a clinical psychologist or a psychiatrist or both is more
appropriate, depends on a person's specific problems. Whereas
clinical psychologists and psychiatrists often deal with mental
disorders, counseling psychologists customarily deal with
adjustment issues and issues related to employment that are
encountered by relatively healthy people (13).

It is also important to realize that, if people need to seek
professional help from a mental health professional, it does not
necessarily mean that they are "crazy." Although many
mental health professionals do treat people with mental disorders
that people generally associate with being "crazy,"
such as schizophrenia, many mental health professionals help
people with other problems associated with stress. In fact, some
mental health professionals specialize in stress management and
see people who only need help with stress. Furthermore, it is
important to remember that any legitimate professional is also a
great resource for a person who wants advice on how to avoid the
problems associated with stress.

B. The Process of
Change

Five stages are involved in changing behaviors that contribute
to health-related problems, such as the problems associated with
stress:

Precontemplation: People do not notice a problem
and have no intention of changing it any time soon.

Contemplation: People realize they have a problem
behavior that should be changed and are seriously
thinking about changing it.

Preparation: People have a strong intention to
change it, have specific plans for changing it, and have
already taken preliminary steps toward changing it.

Action: People are successfully working on
changing the problem behavior.

Maintenance: People take steps to make sure the
new behavior remains and the problem behavior does not
return (131).

Although progress through these stages may appear simple and
straightforward, it usually is not. People usually cycle through
these stages several times before they are able to stay in the
maintenance stage (130). Whether people are able to
move from one stage to the next depends a great deal on decisional
balance, the relative impact of the advantages and
disadvantages on the decision about whether to change a behavior
or leave it as it is (132).

C. Stress Management
Techniques

Countless stress management techniques have been used for
stress management. These techniques usually involve cognitive-behavioral
approaches, relaxation, exercise, diet
and nutrition, and/or medication.

Cognitive-behavioral approaches to stress management attempt
to change stress-related thoughts, feelings, and actions.
Cognitive-behavioral techniques traditionally have been used
within the context of three types of therapies: cognitive
restructuring, coping skills therapies, and problem-solving
therapies(Mahoney & Arnkoff, as cited in 44).
More recently, however, the same principles have been
incorporated into self-help methods.

a.
Cognitive Restructuring

The goal of cognitive restructuring is to establish patterns
of thinking that are more adaptive (44) and less
stress provoking. Examples of cognitive restructuring are rational-emotive
therapy(50), rational behavior therapy (104),
cognitive therapy (16, 18, 19, 20), self-instructional
training (Meichenbaum, as cited in 44, 111, 112),
and structural psychotherapy (74).

A fundamental concept in rational-emotive therapy is the ABC
model. According to this model, consequences (C;
i.e., stress responses) occur as a result of beliefs (B;
i.e., appraisals) about antecedents (A; i.e.,
stressors). The main purpose of rational-emotive therapy is to is
identify irrational beliefs (i.e., stress-provoking appraisals)
and reveal why they do not make sense (50). A unique
feature of rational-emotive therapy is the philosophical emphasis
of its major goals (44):

Self-interest

Social interest

Self-direction

Tolerance of self and others

Flexibility

Acceptance of uncertainty

Commitment to vital interests

Self-acceptance

Scientific thinking

Realistic expectations in life (51).

Rational behavior therapy is essentially the same as
rational-emotive therapy, but it lacks the obvious philosophical
emphasis of rational-emotive therapy and focuses on neuropsychophysiology
(psychological relevance of brain functioning) and learning
theory (44). A central concept in rational behavior
therapy is that rational self-talk, which originates in the left
hemisphere of the brain, is converted by the right hemisphere of
the brain into appropriate emotional behavioral reactions (104).

Both rational behavior therapy and self-instructional training
involve self-talk, but self-instructional training involves a
specific type of self-talk, self-instruction. The idea
behind self-instructional training is that commands made to
oneself can be used in basic behavioral modification processes
like reinforcement (receiving a reward for desired
behavior) (Meichenbaum, as cited in 44). Clients are
taught six types of skills:

Principle No. 1: It is based on a continuously
developing description of the client and his or her
problems.

Principle No. 2: It requires a good relationship
between the therapist and the client.

Principle No. 3: It emphasizes that the therapist
and the client should work together and actively
participate.

Principle No. 4: It is goal orientated and problem
focused.

Principle No. 5: It initially emphasizes the
present, focussing on current problems and current
stressful situations.

Principle No. 6: It strives to teach the client to
be his or her own therapist and emphasizes relapse
prevention.

Principle No. 7: It aims to be time limited,
involving a limited number of sessions.

Principle No. 8: The sessions are structured.

Principle No. 9: It teaches clients to identify,
evaluate, and respond to dysfunctional thoughts and
beliefs.

Principle No. 10: It uses a variety of techniques
to change thoughts, feelings, and actions (20).

In particular, clients are taught the following skills:

Monitoring automatic thoughts

Recognizing the relations between thoughts, feelings, and
actions

Testing the validity of automatic thoughts

Substituting more realistic thoughts for distorted
thoughts

Learning to identify and change the underlying
assumptions or beliefs that make themselves more likely
to engage in faulty thinking patterns (Kendall &
Bemis, as cited in 44)

Structural psychotherapy is similar to cognitive therapy, but
requires that an understanding of the development of and current
role of the clients knowledge of himself or herself and the world
be established (74).

The goal of coping skills therapies is to develop a set of
skills designed to help people cope with a variety of stressful
situations (44). Examples of coping skills therapies
are systematic rational restructuring (68; 69),
anxiety-management training (159), and stress
inoculation training (111; 112; Meichenbaum, as cited in
44).

The purpose of systematic rational restructuring, an extension
of systematic desensitization (reducing fears through
gradual exposure to feared stimuli paired with positive coping
experiences (13)), is to provide clients with more
effective coping abilities by teaching them how to change the
thoughts that occur automatically in anxiety-provoking
situations. Systematic rational restructuring consists of five
stages:

Exposure to anxiety-provoking situations through imagery
or role-playing

Self-evaluation of anxiety level

Monitoring of anxiety-provoking thoughts

Rational reevaluation of the anxiety-provoking thoughts

Self-evaluation of anxiety level following the rational
reevaluation (Godfried, as cited in 44)

Though anxiety-management training, clients learn to use
relaxation and competency skills to control anxiety without
paying any attention to the anxiety-provoking stimuli (159).
Clients visualize anxiety-provoking scenes that may be unrelated
to their specific problem and then practice relaxation skills and
imagine responding intelligently (158).

The rationale for stress inoculation training is that, if
clients can learn how to cope with mild levels of stress, they
will be prepared for or "inoculated" against
uncontrollable levels of stress (44). Stress
inoculation training consists of three stages:

Conceptualization phase: Therapists establish a
working relationship with clients and help them
understand the nature of stress.

Application and follow-through phase: Clients
practice using their coping skills in response to real or
imagined stressors (112).

c.
Problem-Solving Therapies

The goal of problem-solving therapies is to develop general
strategies for solving a wide range of problems. Problem-solving
therapies are essentially a combination of cognitive
restructuring and coping skills therapies (44). In
general, problem-solving therapy involves fives stages:

General orientation or"set":
a vague familiarity with the problem

Problem definition and formulation: determining
exactly what the problem is

Generation of alternatives: coming up with
several possible ways to try to solve the problem

Decision making: deciding which method to use to
try to solve the problem

Verification: evaluating how well the chosen
method worked to solve the problem (47)

Personal science teaches clients to use the skills used by
researchers to solve problems. The mnemonic SCIENCE represents
seven basic skills:

S: Specify general problem area

C: Collect data

I: Identify patterns or sources

E: Examine options

N: Narrow and experiment

C: Compare data

E: Extend, revise, and replace (Mahoney, as
cited in 44)

Self-control therapy uses a variety of techniques to teach
clients how to correct six potential deficits in self-control
behavior across three phases of self-control that relate to
depression. In the self-monitoring phase, potential
deficits include selectively paying attention to negative events
and selectively paying attention to immediate instead of delayed
consequences of behaviors. In the self-evaluation phase,
potential deficits include being overly critical of oneself and
inaccurate conclusions about responsibility. In the self-reinforcement
phase, potential deficits include not rewarding oneself
sufficiently and punishing oneself too much (65; 133).

The purpose of relaxation techniques is to reduce stress
responses. Sometimes it is easy to relax just by getting a
massage, listening to calming music, or admiring peaceful works
of art. Similarly, simple environmental or ergonomic changes in
people's lives can be relaxing by allowing their interactions
with specific objects and their surroundings in general to be
less strenuous. Other times, however, people have trouble
relaxing and need to learn relaxation techniques. Relaxation
techniques include progressive muscle relaxation, autogenic
relaxation, meditation, the relaxation response,
diaphragmatic breathing, biofeedback, self-hypnosis.

Progressive muscle relaxation is accomplished by focusing on
muscle groups one at a time and tensing them for a few seconds,
releasing the tension, and focusing on the resulting feelings of
relaxation (23; 83).

In most types of meditation, people use special techniques to
focus their attention on one thing until they stop thinking about
anything and experience nothing but "pure awareness" (21).
People who meditate seem to have fewer problems associated with
stress, such as general anxiety, high blood pressure, and
insomnia (15). The relaxation response is a
stripped-down version transcendental meditation, a form of
mediation in which attention is focused on softly repeating a
specific vocalization (the mantra). The relaxation
response isolates this aspect of transcendental meditation (13),
and has been shown to reduce the stress hormones levels (21;
22)

Diaphragmatic breathing is sustained, slow, rhythmical,
breathing that emphasizes the use of the diaphragm (54).
It can be thought of as a special way of breathing with your
stomach area instead of your chest area.

With biofeedback, special equipment records stress-related
physiological activity in people like heart rate, blood pressure,
and muscle tension and relays this information back to them as a
tone that changes frequency or a meter reading. The person uses
this information to learn to control these physiological
processes and reduce the stress responses (Budzynski &
Stoyva, as cited in 23)

Self-hypnosis is exactly what it sounds like, hypnotizing
oneself. Self-hypnosis can be used to give oneself suggestions of
relaxation. Hypnosis is a highly relaxing state in which people
are more responsive to suggestions (90). People
display five main changes while under hypnosis:

Reduced planfulness: They do not initiate actions as
much.

Attention is redistributed: They tend to pay attention
exclusively to the voice of the hypnotist (which is their
own voice during self-hypnosis).

Improved ability to fantasize: They are better able to
vividly imagine scenes or to relive remembered events.

Better role-taking ability: It is easier for them to act
like other types of people, such as people of different
ages or the opposite sex.

Reduced reality testing: They are less likely to question
the truthfulness of statements and are more willing to
accept apparent distortions of reality (77; 78).

Aerobic exercise, weight lifting, yoga,
and tai chi are examples of forms of exercise that can
help with stress.

Aerobic exercise uses the large muscle groups in continuous,
repetitive motions and involves increased oxygen intake and
increased breathing and heart rates. Aerobic exercises include
the following types of exercise:

Running

Swimming

Brisk walking

Bicycling

Rowing

Jumping rope (177)

An exercise program aimed at improving physical fitness should
include aerobic exercise 3 to 4 times a week for 20 to 30 minutes
preceded and followed by a 5- to 10-minute warm-up and cool-down
period, respectively (6; 152).

Weight lifting can be used to enhance muscular strength
or muscular endurance. Muscular strength is how much
force muscles can exert, and muscular endurance is how long
muscles can work before getting too tired (10).
Strength training involves lifting heavier weights for fewer
repetitions. Endurance training involves lifting lighter weights
for more repetitions (42). An exercise program aimed
at improving physical fitness should include strength training
with 8 to 12 repetitions of 8 to 10 types of lifts at least twice
a week (American College of Sports Medicine, as cited in 10).

Yoga involves aspects of meditation and special physical and
breathing techniques used to control bodily processes like heart
rate and blood pressure (99). It is one of the six
orthodox systems of Indian philosophy (136). Yoga is
not a religion, though; it is a way of life, combining the body,
mind, and spirit (54).

Tai chi (also called tai chi chuan) is a style of
martial art based on the Chinese philosophy of Taoism. According
to tai chi principles, everything in the universe is made up of
two opposing yet united forces, yin and yang.
Tai chi movements are intended to build up the Qi, the
intrinsic energy that runs throughout the body along pathways
know as meridians. The object is to harmonize the body
and mind and become aware of internal conflicts that may be
causing tension (54; 102).

Switching to a diet that is healthier can relieve stress for
people who do not already have a healthy diet already, especially
for people who are overweight. No dietary secrets or miracle
diets can lead to long-term stress reduction (or weight loss).
People just need to eat right (54). The following
recommendations may be helpful for people who want to improve
their diet:

Eat more fresh fruits and vegetables, enough so that
fresh fruits and vegetables make up 50% to 75% of your
diet.

Ginseng (also called panax ginseng) and
Siberian ginseng help with short-term stress.

Withania helps with long-term stress and
recovery from illness and fatigue. (34)

Catnip causes drowsiness.

Chamomile is a gentle relaxant and helps with
stress-related digestive problems.

Hops helps with nervousness and restlessness.

Kava kava relaxes the mind and the rest of the
body.

Passionflower is calming.

Polygala root is soothing and calming.

Sour jujube seed is soothing and calming. (11)

Regarding herbs, it is important to remember that they can
interact with medications that people may be taking and may have
adverse sideeffects for some people. Advice from a professional,
such as a physician or an herbalist, should be sought before
taking herbs.

5.
Medication

Over-the-counter pain relievers are used frequently by many
people to relieve the pain of some problems associated with
stress (13). Regarding prescription drugs for stress, amitriptyline,
an antidepressant drug, has been used to treat tension headaches (113).
Additionally, a wide variety of prescription drugs are used to
treat mental disorders and physical illnesses associated with
stress. Anxiety and depressive disorders, for instance, are often
treated with antianxiety agents and antidepressants,
respectively. Examples of antianxiety agents are as follows:

Neighbors, B. D. (1994). The impact of family of
origin stressors on young adult psychological
functioning: Issues of longitudinal and concurrent
prediction and mediation. Unpublished doctoral
dissertation, University of Georgia, Athens.

Pierce, G., Sarason, I., & Sarason, B. (1991).
General and specific support expectations and stress as
predictors of perceived supportiveness: An experimental
study. Journal of Personality and Social Psychology,
63, 297-307.

Vitaliano, P. P., DeWolfe, D. J., Maiuro, R. D., Russo,
J., & Katon, W. (1990). Appraised changeability of a
stressor as a modifier of the relationship between coping
and depression: A test of the hypothesis of fit. Journal
of Personality and Social Psychology, 59, 582-592.

Walker, J. R., El-Guebaly, N. A., Ross, C. A., &
Currie, R. F. (1992). Where do you turn for help? A
community survey of the use of professionals, reading
materials, and group programs for three problems in
living. Journal of Community Psychology, 20,
84-89.